RE: Ruth Evans
AB: Agnes Binagwaho
PF: Paul Farmer
SN: Sabin Nsanzimana
Clip: “This province lost about 120,000 people.”
RE That’s over a fifth of your population died in the genocide.
“They did yes.”
RE After the 1994 genocide which claimed up to a million lives Rwanda was one of the poorest countries in the world. The health system had collapsed and epidemics of infectious diseases including AIDS, malaria and tuberculosis were having a devastating impact on the country.
Today, however, Rwanda’s economy has been transformed and its gross domestic product more than tripled over the last decade. And alongside this economic growth Rwanda has also recorded some remarkable outcomes in health. In the last 10 years the country has been dramatic declines in premature mortality with deaths from AIDS and TB falling by 78% some of the greatest declines in Africa. Maternal mortality also declined by 60% and under five child mortality by 70% to less than half the regional average.
Doctor Paul Farmer, professor of global health at Harvard University was one of the authors of a recent article in the British Medical Journal.
PF It’s important for the world to understand this because these are the steepest declines in mortality ever recorded at any time and in any place; and if we can’t explain coherently how that came to pass it would be a shame for other places where we’d also like to see steep declines in mortality and early suffering.
RE I’m Ruth Evans and in this month’s development podcast we’ll be examining what Rwanda has achieved in the health sphere and asking how it’s done this and are there any lessons for other countries?
AB I think all the people in the world want their children to be healthy, in better shape than they were themselves, but educated, and really to be a bit more rich.
RE Agnes Binagwaho is Rwanda’s minister of health. She says health is a key pillar of the government’s vision 2020 strategy for economic development and poverty reduction.
AB We totally understand that health is a social issue. That mean they are a social determinant of health and if we just look at the ministry of health we will get nowhere. We need to tackle the social determinant of health if we want to improve the health status of our population.
RE And as a result she says Rwanda spends some 16% of the national budget either directly or indirectly on healthcare with much of it financed by foreign aid in the past. But it is isn’t just a question of throwing money at the problem. Rwanda only spends $ 55 or about £35 per person on health a year, slightly lower than the average for its neighbours. And in 2010 it also only had 625 doctors for a population of some 12 million people.
At the National AIDS Day celebrations in December Kigali stadium was full to capacity with young people wearing bright orange and green T-shirts and the mood was colourful and festive. But 20 years ago there was little to celebrate. AIDS and TB were two of the biggest causes of premature mortality after the genocide. Many woman had been raped and infected with HIV and the government faced a huge challenge. By December 2002 only a handful of tens of thousands of Rwandans with advanced HIV were receiving expensive antiretroviral therapy or ARVs, mostly through private clinics says Doctor Sabin, head of Rwanda’s HIV AIDS programme.
SN That time was actually no treatment, there was not even testing available until 2003 when the large scale of programmes was started really in Rwanda in opening of new facilities, voluntary counselling and testing, and even ARVs becoming easy, especially with the government linking it to the bad history of bad genocide that the country had passed on a number of cases of rapes and so on. So that was really the top priority of the new government to make sure that HIV is not going to be another big threat after those dark moments.
RE From the start Rwanda’s AIDS programme was characterised not only by efforts to address both prevention and treatment but also by the recognition that the epidemic couldn’t be tackled without addressing other problems such as opportunistic infections and malnutrition. The entire healthcare system would need to be strengthened.
SN We have already unrolled 122,000 of ARVs, which represent according to the treatment criteria, about 94% of those in need.
RE Having the drugs is one thing, making sure that people adhere to the protocols of taking them is another. And a lot of people doubted that relatively poor African countries where malnutrition is also a problem that people would adhere to the drugs. Has Rwanda disproved that do you think?
SN We have seen really very good adherence, more than 83% of people adhere very correctly. And we have seen a lot of change in terms of controlling the epidemic both for prevention and for treatment. Beds are being empty in hospitals just because people are receiving ARVs and not becoming very sick.
RE Today the general prevalence of HIV is 3% the same as 10 years ago and the antiretroviral drugs are free. According to the World Health Organisation by 2010 Rwanda, along with much richer Botswana, was one of only two countries in sub-Saharan Africa to have achieved the United Nations goal of universal access to antiretroviral therapy.
At a clinic in Gasabo district on the outskirts of Rwanda’s capital Kigali, a doctor is sorting the tablets to give HIV positive patients. So these are the antiretrovirals. You have a cupboard full of drugs here. You have plentiful supplies but 10 years ago there weren’t any antiretrovirals in this country, or very few, they were very expensive; so can you describe to me what difference having those antiretroviral drugs has made to the lives of the women that you see.
Translated: “The death threat was high before but at this time it has really changed. If you even see them their appearance has changed. You can’t tell if they are HIV positive or not. There is a great impact since they have started having this medicine for free.”]
RE When I first met Chantal 10 years ago she was sad, traumatised and very sick. She’d lost all her family in the genocide, had been raped multiple times and found herself not only pregnant as a result for HIV positive. Today she still lives in a village on the outskirts of Kigali with her son who is now 19. Life continues to be very hard but the transformation in her appearance is dramatic.
Translated “I take two tablets a day. There are 30 tablets.”]
RE When we first met they were only just introducing antiretrovirals into the country and they were difficult to get and you didn’t even have the bus fare to go to the clinic to go and see if you could have antiretrovirals. But now you have the medicine and you don’t have to pay for it, is that correct?
C [Translated] “Yes we get the medicine for free. But you can’t take the medicines without having something in your stomach. This year I did not cultivate anything because I was very ill. I had a very serious cough. I also went to the hospital so there is nothing in my garden because this year I did not plant anything.”]
RE But generally you feel healthier than you were 10 years ago?
C [Translated] “We get used to it. I’m still ill and I’m still sad but I’ve got used to it. These medicines have many side effects, you can have a liver problem. They also cause something in your stomach which they need to operate. But there are some other medicines which the medical insurance doesn’t pay.”]
RE Medical insurance is another pillar of Rwanda’s health strategy for universal health coverage. The aim is to reduce out of pocket expenditure which can have a catastrophic effect on poor families like Chantal’s. A community based scheme has been rolled out nationwide and according to the minister of health by June 2012 over 90% of the population had been enrolled with another 7% covered by civil service, military or private insurance plans.
AB It’s a universal coverage scheme across the country for each and every one. The object is to decrease catastrophic expenditure. That means that this instrument is owned by the people and reimburse the care the people have. It’s for paying for them to get care.
RE Was there a resistance from the communities initially; was there a huge campaign to educate people about why they should have to pay this insurance?
AB No I think the minister of health and the first lady submit a project to global fund and this project aim to pay the health insurance of the million poorest. When the people saw how the poorest got access to care it was almost automatic. First of all this insurance is community owned, so this is a success. Secondly, it has increased access to care and increased the uptake of corrective care.
RE And they still have to pay 10% of their care upfront?
AB Yes.
RE So they’re out of pocket. But this is a much smaller proportion than they would have had to have paid before.
AB Absolutely. We don’t want to give free care like this. We pay at point of care so that people understand that care has a cost. And they want to graduate from poverty it’s something to make them proud to pay for themselves and we don’t believe in free things.
RE There’s no doubt that this insurance scheme has helped far more people to access healthcare they might not otherwise have been able to afford.
Translated “It’s really a good system, it helped. You just need to have 200 when you’re going to the hospital. Only 200. And for the medicine you can pay only 500. And before you could pay, let’s say, 5,000 so it’s a good system, it really helps. If you have the medical insurance in the house you can go anytime to the hospital.”]
RE Initially this insurance was a flat rate payment but now it’s more complex. Since 2006 the poorest have been subsidised by a three tiered fee structure. Even though many genocide survivors like Epephanea are poor and live in very basic mud houses with leaking tin roofs and even though they have many ongoing complications from HIV they don’t qualify for the free insurance category.
E [Translated] “There was this new system introduced to put people in different categories. So we are not on the category of people who they help to pay for medical insurance. Before it was only 1,000 but they have increased their price up to 3,000. After genocide we tried to work hard so that we can show the people who killed our people that we are still able and still have power to do something and we managed to get something. So if they see it they think that we are rich when we are not.”]
RE Each household has been assessed according to how much land or how many cows it has. But the problem is that the assessment was only done once and people’s circumstances change. For many poor people the insurance for their families can be the equivalent of a month’s rent or a term’s school fees.
As she shows me her insurance papers Chantal says it’s a struggle to find the annual payment of 3,000 Rwandan francs or just under £3 for herself, her son, Bertrand, and Alice, a genocide orphan that she also looks after.
C [Translated: "I had to pay 9,000 it"s a lot because I also need to get something to eat. I was in the third category where I had to pay the medical insurance for everything because they said that if someone owns a house they can pay for their medical insurance."]
RE But is it better to have the health insurance and have to pay less when you need to go to see a doctor or go to a clinic? Is that better than the system before when you had to pay everything upfront out of your pocket?
C [Translated] “The medical insurance it’s good for women who are going to give birth to the hospitals. But for me it’s always hard. I can’t say that paying 100% is also easy but it looks the same to me because I don’t get enough medicine.”]
RE The universal health insurance system may not be perfect says Doctor Paul Farmer who is also the co-founder of the International Non-governmental partners in health. But he says it’s a huge step in the right direction.
PF Are there problems? Of course there are problems but they’re not as bad as the ones we just saw in the United States with the roll out through the, again, great technological tools, but in Rwanda they rolled this out in the course of a couple of years. And did they have a lot of help? Sure they had partners of course. Are we proud to be their partners? I’m sure those who help finance it and think of it – the multilaterals and bilaterals, I’m sure they’re proud of it too, they should be. But the Rwandans need to say hey we did this and we did it imperfectly but with the aspiration in mind of having a universal social protection that reaches everybody. And however difficult any kind of barrier, such as co-payments are, however problematic those are the idea of universal coverage is the most important one.
RE But improving access to care also increases demand for services and Rwanda faces one of the greatest shortages of human resources for health in the world. Many health professionals were killed during the genocide and countless others have left. Efforts are now underway to train new doctors and nurses but this will take many years. Meanwhile 45,000 community health workers, three for each village or cell, have been elected by communities and trained by the Ministry of Health to take care of many basic primary healthcare tasks.
AB They are really our voice house to house on how to prevent HIV, how to adhere to treatment if we are HIV positive, how to go for HIV diagnosis if you are a pregnant woman, how to deliver in a health centre. They are our voice and allow us to be really client centric.
RE These community health workers play a key role in family planning, antenatal care and childhood immunisation campaigns. They can also refer patients to health centres and hospitals. They’ve also been trained to diagnose and give treatment for malaria, pneumonia and diarrhoea. What differentiates Rwanda’s community health workers from similar schemes in other African countries is the number. Ethiopia, for example, has 38,000 community health workers for 93 million people; whereas, as we’ve heard, Rwanda has 45,000 for just 12 million.
AB As they are volunteers we don’t want to overload them. Of course we award them against service rendered but it’s not so much. So we better have people who are very well known in the village; a village is 100 to 200 houses, very well known, elected, we train them so that they are available they don’t have to go far to give services and they can continue their day to day life and other job they have. So we deliberately chose the village as a unit, a couple to run the services and add a third one to just take care of pregnant women and new born for the first years. So that’s how they became 45,000.
RE For the past eight years Cecile has been one of three elected community health workers responsible for 750 people in Kibirizi village in Southern Rwanda. She proudly wears a uniform with pictures of mosquitoes and messages about malaria printed on the blue cloth.
C [Translated] “I’ve had many trainings. We agreed to treat malaria, diarrhoea and cold diseases. We also look to the malnutrition for the children. I love giving advice to people who need it and giving treatment to children and I see them recover. I really love my job. We also check malaria and we know which medicines to give them and whenever it’s complicated we give them transfer to hospitals.”
RE Deaths from malaria dropped dramatically by 87% between 2005 and 2011. And as we’ve heard maternal mortality also fell by 60% and under five child mortality by 70%. Doctor Paul Farmer has analysed the reasons for these dramatic results.
PF There is no question that community health workers are a big part of the reductions in mortality that have been documented in this country because there the delivery mechanisms for a lot of the deliverables whether it be a bed net, a malaria bed net, or a vaccination campaign or care for pneumonia – whatever the deliverable is the idea that doctors and nurses are pushing those deliverables out to communities it’s not true. You just look at the human resource challenge or crisis in Rwanda you see it can’t be the doctors or nurses because there just aren’t enough of them to account for it. It has to be community health workers.
RE A performance based pay system is also being introduced to reward not only community health workers but health centres and hospitals when they hit targets such as increasing the proportion of women delivering at health facilities or the number of children receiving a full course of basic immunisations.
J My name is Joseph I’m head of health centre.
RE Joseph manages a health centre serving 55,000 people in Kigali and he says the financial incentives to meet targets are popular with his staff.
J [Translated] “It makes them happy. They get the bonus money according to what services they are giving. It also encourages them to give better services so that they could get better money.”]
RE In the last 10 years Rwanda has made a great deal of progress in the health sector. How have you seen that manifest here in the clinic in terms of the facilities that you can offer people and also the types of illnesses that you are dealing with?
J [Translated] “There has been great change. Death threats have gone down for the pregnant women and for children who are under five years. And we also take good care of people with HIV. So the numbers of deaths has really gone down. We work with healthy workers in the villages and in the cells to give advice to people who are sick, especially for the children who are under five years. And whenever the problem is great they are sent here to the health centre to be taken care of.
We have introduced a new system where they use mobile phones to send SMSs, it’s called ‘Rapid SMS’. If they have a problem they could immediately send it to Rapid SMS so that we know what the problem is. We also have a system where they give monthly reports through mobile phones. We get the reports immediately using the Rapid SMS. It has really helped a lot.”]
Translated “We have been given this phone by our parent our parent Kagame … His Excellency. It has really helped us a lot. When a woman is pregnant and is about to give birth we can use it to call to the health centres to send the ambulance. Or if someone is sick and his sickness is complicated we can use it to ask how to give him treatment so it really helps.”]
RE Rwanda has been quick to adopt many technological and clinical innovations including a comprehensive health information management system says the minister of health.
AB Of course with the technology we can overcome the lack of health personnel because those community health workers where lay people can ask advice and take good decisions with remote support of professionals. We use technology to report. We have a very good health information system that allows us to know our epidemiological situation and take the right decision at the right time and also to know if there is a part of the country that has a strange report. So we go there and try to find out. So this is timely. Before it would take us six months to analyse a lot of people. Now we have artificial intelligence to help us for that.
RE So it’s really transformed the communication within the country both in terms of being able to disseminate things from the centre to the community health workers and for them to be able to alert you when there’s a problem.
AB Before we had 15,000 reports, nobody can read 15,000 reports.
RE Another significant success has been immunisation with the government claiming 93% coverage for nine childhood vaccines. Measles used to kill a lot of children but in 2012 there were only two cases in the country. And the last confirmed case of polio was 20 years ago says Doctor Maurice Gatera, head of Rwanda’s immunisation programme.
MG What makes most of them a success it is integration at central level, the seed level, the facility level and the community level. At national level our division is working on the malaria programme. Where we try to integrate mosquito nets with immunisation programme. And our immunisation cards contain also nutritional status. At the community level also we use outreach services – you go to the community … that makes a success of immunisation programme. So far all children in Rwanda have received vaccine at 90% and measles vaccines at 97%.
RE Doctor Gatera says vaccination saved the health service money in the long run because fewer children have to be treated for diseases at clinics later.
MG Everybody, every parent, he knows that the child has to be immunised. It has become a culture. And what mostly make the success of this programme it is because of the community own it. We think about our Rwandan babies in the future.
RE The slogan on one of your vehicles outside was ‘A Healthy Country is a Wealthy Country’.
MG OK.
RE That was on a vehicle outside. So do you think that health is actually a prerequisite for development that you cannot have economic progress and development without a healthy population?
MG Yes sure. To invest in health it is to invest in the future economy of the country.
RE Rwanda has also introduced an HPV or human papilloma virus vaccination programme against cervical cancer. Doctor Gatera says this has so far covered 97% of eligible adolescent girls compared to only a quarter of eligible girls in the US. The vaccines have been given through the schools during a nationwide four day campaign, and community health workers have followed up with any girls who were not at school. This new vaccine has been quite controversial partly because the vaccines were initially a donation from the pharmaceutical company that makes them. But the minister of health is adamant that this is the right way to go.
AB We know that this vaccine is efficient at a very high percentage, safe and we were able to provide it so it should be really almost criminal not to go and fight for it. So we did.
RE The vaccination was donated by Merck, was that right?
AB Yes.
RE And that was quite controversial wasn’t it?
AB Yes but it’s controversial for little minds not controversial for global health of people who want really the health of people to be cared. Public/private partnership is the future.
RE Some sceptics claim that Rwanda’s progress largely reflects high spending on healthcare much of it financed by foreign aid. Others argue that the 1994 genocide resulted in a unique opportunity for reform; so Rwanda’s experience really doesn’t apply in other countries. But Doctor Paul Farmer disagrees.
PF It is true that the government has had substantial developmental assistance. It’s pretty easy to say, “OK here’s the hypothesis that is donor largesse that has driven forward this decline in mortality.” That is false because we can just say compare the amount of aid that Rwanda received per capita with all of the neighbouring countries or some of the other places I’ve worked in like Haiti and you’ll see that that’s a false hypothesis. The amount of investment per person in the health sector has been less than surrounding countries. So it’s again the way that those resources have been used that’s been distinctive here.
RE Doctor Farmer says substantial credit for Rwanda’s progress must go to the efficiency and vision of the central government. The same government that has been widely criticised by the international community for its poor record on democracy and human rights. But the health successes are widely acknowledged and appreciated by ordinary Rwandans.
Translated “The government of Rwanda they have really tried very much because before people were killed by malaria. Women who were pregnant were killed by malaria. Children who were under five years they were killed by malaria but it has really changed. There are many people who are suffering outside here but still the government is still doing what it can.”
RE But the minister of health maintains that Rwanda’s achievements are not merely the result of a top-down approach to health policy.
AB The health agenda has been done with a huge participatory process; that mean the population has owned it, civil servants have owned it and parliamentarians have owned it so that means everybody was around one agenda. So it was a huge dialogue around each agenda in the health sector. So this is the key factor of the success.
RE Doctor Paul Farmer believes that there are many interwoven reasons for Rwanda’s successes but one stands out for him.
PF The real secret is the commitment to equity. And to see that play out from some grand idea, let’s have justice and fairness and equity, into delivery and that’s been really something here – quite unique. And I’ll give an example when you actually say the poorest quintile receive the majority of our attention and we’re also going to go to the more rural areas that have been historically underserved and women’s groups to actually turn those ideas into policies that then get delivered then that’s the secret sauce linking this equity vision to real delivery.
RE According to Doctor Farmer and other global health experts if these gains can be sustained Rwanda will be the only country in the region on track to meet each of the health-related millennium development goals by 2015. Yet, not long ago it was the country least likely to do so. Many challenges still lie ahead however, for example, chronic childhood malnutrition remains high, with 44% of children classified as stunted in 2010.
AB It’s a big challenge educating people what to put in the plate of a child. There was great progress because now we are number one in east Africa, and fifth in Africa in tackling that – but we still have a long way to go.
RE The government recognises that Rwanda will face great challenges if it is to meet its stated goal of becoming independent of aid by 2020. Nearly half of its health sector budget was externally financed in 2010 and the decision by several foreign donors to suspend or withhold aid last year, a response to Rwanda’s involvement in Eastern Congo, could have serious implications for the future sustainability of the country’s health gains. But Doctor Farmer believes the challenges ahead do not diminish the present successes and he says there are many lessons Rwanda can offer other countries not only in the developing world.
PF I think there are a lot of places that can learn from this experience and it’s not just the United States again that has a lot to learn, it’s shaking faith in social production in some European countries they’re saying, “Well we can’t do it” or “it’s not sustainable” or whatever the ‘it’ is, but the Rwandans I think are showing us that this idea of universal coverage, and when people ask me is it sustainable the first thing I think yes this is the only thing that is sustainable. I think it’s not sustainable to not do what Rwanda’s doing, to not think about equity of access to care, to not think about the burden of disease, to not think about innovation both in bringing in new tools whether they be a new treatment, a new vaccine, new communication platform – it’s not sustainable to not do that.
RE Doctor Paul Farmer ending this month’s development podcast. My thanks go to Sadiki Businge my translator, and the European Journalism Centre for the International Developing Reporting Grant that facilitated my trip to Rwanda.
For more great downloads go to theguardian.com/audio
Rwanda"s wellness services evolution – podcast transcript
